Seven years after Thackersey empire scion Sudhir Thackersey’s wife Nina won a Rs 52-lakh compensation against New India Assurance Company for rejecting her foreign medical claim, the Delhi-based National Consumer Disputes Redressal Commission ruled on Thursday that Nina had committed an “insurance fraud”. Nina, 80, has also been fined Rs 1 lakh, which includes concealing facts about her health while buying insurance among other anomalies. The commission also issued Nina a “stern advice of caution”.

Setting aside the Maharashtra State Consumer Disputes Redressal Commission order of June 2012 that “erred” in rejecting her claim, the commission said that in this case, there was a “mala fide, pre-meditated attempt” to commit an “insurance fraud”.

Thackersey, the nephew of late cricketer and industrialist Vijay Merchant, is chairman emeritus of Hindoostan Spinning and Weaving Mills Ltd. In 2010, his wife Nina bought an overseas mediclaim policy from New India Assurance Company for $1,00,000 towards illness and treatment for accident for the period April 26, 2010 to April 25, 2011.

While on a trip to Zurich on May 9, 2010, she complained of upper abdominal pain, following which she was admitted at Klinik Hirslanden. She was admitted in the intensive care unit where she underwent dialysis and was discharged on May 28, 2010. Nina claimed she was asked to stay back for four days at a Zurich five-star for “consultation and final examination”. She said that a doctor issued her a letter saying she should return to India accompanied by a medical professional. She returned to India on June 2, along with Sudhir and an Indian doctor. The commission, however, noted that the Indian doctor’s tickets were booked even before the said letter was issued.

Nina then filed the requisite claim with the insurance company which rejected it claiming she had suffered abdominal pains due to alcoholic pancreatitis and liver cirrhosis.

The doctor of the insurance company ruled that the complainant was treated for alcoholic pancreatitis and liver cirrhosis and that the ailments relating to alcoholism were excluded from claim and hence not payable. It was also revealed that she suffered from diabetes which was not revealed at the time of buying insurance.

The patient’s claim

In her complaint submitted to the Maharashtra State Consumer Disputes Redressal Commission, Nina said that after her claim was rejected, she travelled again to Zurich for further medical examination, which was billed to the insurance company.

Commission’s verdict

The commission ruled that Nina’s case was an example of “how not to file a claim”. It further said that there were loopholes in her claim, and that the entire sequence of events, right from the time she got admitted to hospital till her return to India with a doctor suggested mala fide intent.

The commission observed that attempts were made to influence the insurance company’s doctor by repeatedly seeking an appointment with him. The commission’s panel of Dr SM Kantikar and member Dinesh Singh said, “It is evident that attempts were made to meet and influence the insurance company’s doctor. If at all any follow-up regarding the claim had to be done, it should have been limited to the managerial officials responsible for processing.”

The panel noted that “such mala fide pre-meditated attempt at insurance fraud, then litigating as a consumer under the Consumer Protection Act was an attempt to misuse the statutory provisions provided for better protection of the interests of the consumers.”

The panel further said that Maharashtra Consumer Disputes Redressal Commission “erred in accepting the claim in its entirety when every part of it was under question”. New India Assurance Company was represented by advocates Dr Sushil Gupta and Ganesh Khanna, while advocate Satvik Varma appeared for Nina Thackersey.